REPUBLIC OF THE PHILIPPINES )

CITY OF ______, METRO MANILA) S.S.

AFFIDAVIT OF LOSS

I, FIRST NAME MIDDLE NAME LAST NAME, of legal age, single, Filipino with
residence at ___________________________________________________________________,
after having been duly sworn to in accordance with law, hereby depose and state, that:

1. I am a doctor of medicine, as such, I was issued a Physician Professional

Identification Card by the Professional Regulation Commission;

2. I am a holder of a Land Transportation Office Non-Professional Driver’s License;

3. On Friday, January 15, 2016, around 7:30 PM, I was at home and arranging the things
inside my bag. I discovered that I misplaced and could not find my wallet. I told my
family about it and sought their assistance to look for the said wallet. Despite all our
efforts to find the wallet, we could no longer find it;

4. Inside my wallet are PRC Physician License and LTO Non-Professional Driver’s
License;

5. I am executing this Affidavit of Loss in order to notify the Professional Regulation

Commission and Land Transportation Office about the lost licenses; and

6. I attest to the truthfulness of the foregoing facts.

IN WITNESS WHEREOF, I have hereunto set my hand this 22nd day of January, 2016
at _____ City, Philippines.

________________________________
Affiant

SUBSCRIBED AND SWORN TO before me this 22nd day of January, 2016 at

__________________________________, Philippines, Affiant exhibited to me his competent
evidence of identity.

Witness my Hand and Seal.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 20___
REPUBLIC OF THE PHILIPPINES )
CITY OF PASAY, METRO MANILA) S.S.

AFFIDAVIT OF LOSS

I, JOEL TOLENTINO DUQUE, of legal age, single, Filipino with residence at Unit
1603, North Tower, La Verti Residences, Taft Avenue cor. Donada St., Pasay City, after having
been duly sworn to in accordance with law, hereby depose and state, that:

1. I am a doctor of medicine, as such, I was issued a Physician Professional

Identification Card by the Professional Regulation Commission;

2. I am a holder of a Land Transportation Office Non-Professional Driver’s License;

3. On Friday, January 15, 2016, around 7:30 PM, I was at home and arranging the things
inside my bag. I discovered that I misplaced and could not find my wallet. I told my
family about it and sought their assistance to look for the said wallet. Despite all our
efforts to find the wallet, we could no longer find it;

4. Inside my wallet are PRC Physician License and LTO Non-Professional Driver’s
License;

5. I am executing this Affidavit of Loss in order to notify the Professional Regulation

Commission and Land Transportation Office about the lost licenses; and

6. I attest to the truthfulness of the foregoing facts.

IN WITNESS WHEREOF, I have hereunto set my hand this 22nd day of January, 2016
at Pasay City, Philippines.

________________________________
Affiant

SUBSCRIBED AND SWORN TO before me this 22nd day of January, 2016 at

__________________________________, Philippines, Affiant exhibited to me
__________________________________ issued on ___________________________________
issued at the City of __________________.

Witness my Hand and Seal.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 20___